WASHINGTON -- During the 13 years since President Bill Clinton lost his bid to remake the U.S. health-care system, and helped cost his party control of Congress in the bargain, politicians have shied from changing it more than one step at a time even as costs and the ranks of uninsured have ballooned.
Now, the growing list of Democratic presidential candidates calling for universal, cheaper coverage -- Illinois Sen. Barack Obama Tuesday became the latest -- suggests the days of health-care incrementalism are over. Nor are these Democrats alone in embracing the once-toxic political cause of universal care: The best-known state models have been championed by Republican governors, including Mitt Romney of Massachusetts, who is now running for president.
This shift reflects rising and inflation-topping out-of-pocket costs for health care and insurance premiums, co-payments and deductibles. Also, the number of uninsured has spiked to about 45 million, from 37 million when Clinton was president. Business leaders increasingly are seeking a government-imposed solution, saying employee health costs put them at a disadvantage with foreign competitors.
Those forces, in turn, have combined to embolden politicians in both parties to once again propose universal health care that inevitably would mean a big role for government -- and possibly upend the powerful insurance, medical and pharmaceutical industries.
Obama's speech unveiling his initiative in Iowa, the state with the first nominating contest, comes a week after Sen. Hillary Clinton of New York proposed health-cost savings as an integral part of a later plan specifically aimed at covering uninsured Americans. The third candidate in Democrats' top tier of White House contenders, former North Carolina Sen. John Edwards, beat both to the punch with a detailed universal-coverage plan in early February.
In Congress, Democratic Sen. Ron Wyden of Oregon and Republican Bob Bennett of Utah have drafted a bill to overhaul the nation's health system. It isn't expected to get off the ground during the current Congress and the remainder of George Bush's presidency, though, given the president's belief in market forces and opposition to government regulation. Moreover, he and the Democrat-led Congress are locked in battle over Iraq. The public likewise is preoccupied with war, polls show, but health care has re-emerged as voters' top domestic concern.
Indeed, the political center on the issue seems to have shifted so much that the health-insurance industry, which undermined the Clinton plan with commercials featuring middle-class couple "Harry and Louise" ridiculing the big bureaucracy it would create, openly supports a federal role in universal coverage. The industry strategy is to shape the result rather than to fight it.
Mohit Ghose, a spokesman for America's Health Insurance Plans, the successor group to the one that fought the Clintons, Tuesday said, "The most important thing for us is that there are plans out there." The group's own proposal for universal health care, unveiled after Democrats won control of Congress, focuses on increasing federal subsidies for insurance, and avoids new mandates or regulations.
The Republican Party also is adjusting to voters' openness to a government role in making health care more affordable and accessible, with the goal of putting its imprint on any changes.
"Republicans have an opportunity to lead on health care by promoting broad-based reform consistent with our principles: consumer choice, market incentives, technology," said former Republican Party Chairman Ken Mehlman.
Republican candidates nonetheless will likely try to blast Democrats for using universal care to boost the size of government and to raise taxes. But they have yet to engage: The Web site of former New York Mayor Rudy Giuliani doesn't list health care among his top 10 issues.
Big employers, while eager for help with the growing burden of employee health costs, are reserving judgment on early proposals. The Business Roundtable, an association of chief executives that recently joined with the seniors organization AARP and the service-employees union to press for a bipartisan solution, issued a statement welcoming Obama's effort "to focus the nation's attention on this critical issue."
Despite the renewed interest in taking on health care, though, no one is talking about an overhaul as ambitious as the 1993-94 Clinton plan -- not even its architect, Clinton's wife.
The Clintons proposed a complex and heavily regulated system based on a mandate for employers to provide health insurance to all employees, and the creation of powerful insurance-purchasing agencies as go-betweens for consumers and health providers. Now, as Mrs. Clinton campaigns for president, a staple of her speeches is a self-deprecating nod to the scars she bears from that fight -- and assurance that, as she puts it, "I know what not to do."
For one thing, Clinton says this time she will seek consensus before moving ahead. While her preference, and that of many Democratic voters, would be a Medicare-style plan for all, she tells audiences it wouldn't be possible to get such a system passed in Congress.
Both the Obama and Edwards plans would work within the current private-insurance system, and mandate that all but the smallest employers either provide health coverage to their workers, or contribute to a pool for the uninsured.
But unlike Edwards, Obama wouldn't mandate that individuals purchase insurance. Given that option, both the Edwards and Clinton camps said the Obama plan wouldn't achieve universal coverage as advertised, since many Americans -- especially the healthy and young -- won't buy policies unless required to do so, thereby keeping premiums and other costs higher.
Obama advisers insisted that as the cost-saving proposals in his plan in turn reduce the costs of insurance, individuals would buy it; if a President Obama found after several years that some share of Americans remained uninsured, "he'd revisit" the issue, they said. At the same time, the Obama aides questioned whether Edwards' plan would accomplish universal coverage; they cited his plan's caveat that individuals wouldn't be mandated to have insurance until it becomes affordable.
To help pay for their plans, both Obama and Edwards would end the Bush tax cuts for the rich, typically said to be those making more than $200,000 a year. That would translate into revenue upward of $65 billion a year, depending on which cuts are eliminated.
Under the Obama plan, the federal government would cover some costs for catastrophic illnesses that account for a huge share of expenses. The senator said this would lead to reduced premiums. He also would mandate that all children be insured, and would expand both Medicaid and the State Children's Health Insurance Program to cover more poor families. States would be able to continue implementing their own plans, as long as they met new minimum coverage standards.
People up to age 25 could continue to be covered under parents' policies. Obama would create a National Health Insurance Exchange, described in campaign documents as "a watchdog group" that would be empowered to set rules and standards "to make individual coverage more affordable and accessible."
While now more willing to accept a government role than they were a decade ago, insurers, as well as pharmaceutical companies, aren't likely to support his proposal any more than they did the 1994 Clinton plan that Republicans still deride as "Hillary-Care." And Obama, despite his reputation as someone who brings all sides together, Tuesday repeatedly lambasted both industries for profiteering and killing all past attempts at change.
"It's time to bring together businesses, the medical community, and members of both parties around a comprehensive solution to this crisis, and it's time to let the drug and insurance industries know that while they'll get a seat at the table, they don't get to buy every chair," Obama said.
Aside from insurers and drug makers, losers would include the wealthiest Americans who would forfeit their tax cuts. Winners, supporters say, would be the 45 million uninsured, as well as everyone else who would see lower health costs. Obama claimed a family of four on average would save $2,500 a year.
To help bring down costs, all three Democratic candidates aim to have insurers cover more preventive care to avert expensive illnesses. And they would have the government subsidize health providers' investments in technology, which they claim could squeeze out big savings, though some experts question how much.